Innovation Adoption Grant: Preliminary Questionnaire


At a basic level, companies should meet certain criteria, including:

  • Located in Southwestern Pennsylvania
  • Currently employ fewer than 250 people
  • Established Manufacturer with products, revenue and customers

A Few Questions


To be considered for investments of risk capital and expertise, we ask that you complete the following questionnaire. Required fields are marked in bold.

Contact Information
 
Title:
 
First Name:  
 
Middle Name:  
 
Last Name:  
 
Suffix:  
 
Company Name:  
 
Job Title:  
 
Address One:  
 
Address Two:  
 
City:  
 
State:  
 
Zip:  
 
County:  
 
Municipality:  
 
Phone Number:   ( ) - x
 
Fax Number:   ( ) -
 
E-Mail:  
 
Web Site:  
 
Additional Company Information
 
If you are from outside the southwestern Pennsylvania region, why are you interested in locating here?
(3 sentences or less)		  
 
Abbreviated company description:
Describe key company products and services. Emphasize differentiating characteristics.
(100 words or less)		  
 
Please attach your business plan or executive summary:
If you do not yet have a business plan, leave this blank.
 
Company Legal Type:  


If a Corporation, what are the state and date of incorporation?


(mm/dd/yyyy)
 
Number of full-time employees:
(total worldwide)		  
 
Management Team
 
1. Name:  
       
    Title:  
 
2. Name:  
       
    Title:  
 
3. Name:  
       
    Title:  
 
Capital Investment to Date
 
Amount:
(in dollars)		  
 
Source:   Angel Investor
Bank
Friends and Family
Self
Venture Capital
Other (please specify)
 
Investment amount that company is seeking from Innovation Works:
(in dollars)		  
 
Other than capital, what are your immediate resource needs?:   Business Mentoring
Corporate Contacts
Management Team Hiring
Professional Services
Other (please specify)
 
How did you hear about Innovation Works?:  
 
Have you had contact with Innovation Works previously?:   Yes No


If yes, with whom did you work?

 

Terms and Agreements
   
  Innovation Works is a non-profit economic development agency serving the citizens of southwestern Pennsylvania. If we agree to provide you with business assistance, we will do so at no charge to you. We disclaim (and you waive) all warranties related to the assistance we may provide to you, and you also agree that neither Innovation Works, its directors, officers, employees nor agents shall be liable to you for any damages, including, without limitation, loss of profit or business opportunity.

I Agree